Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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On Sep 2018

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Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
On Aug 2018

Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".

Dr. Mamta Gupta
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018

Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.

Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
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Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
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Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."

Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
On May 11,2011

Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."

Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
On April 2011

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.

Dr. Anuradha
On Jan 2020

Important Notice

Original article / research
Year : 2022 | Month : March | Volume : 16 | Issue : 3 | Page : LC06 - LC10 Full Version

Community Based Appraisal of Healthcare Service Utilisation and Determinants of Health Seeking Behaviour among the Elderly Population of Rural Western Maharashtra

Published: March 1, 2022 | DOI:
Sachin B Jadhav, Kalpak S Kadarkar, Harshawardhan N Mujumdar

1. Associate Professor, Department of Community Medicine, Government Medical College, Miraj, Maharashtra, India. 2. Assistant Professor, Department of Community Medicine, Government Medical College, Miraj, Maharashtra, India. 3. Postgraduate Student, Department of Community Medicine, Government Medical College, Miraj, Maharashtra, India.

Correspondence Address :
Kalpak S Kadarkar,
Kalpataru Housing Society, College Road, Sangamner, Ahmednagar, Maharashtra, India.


Introduction: To mitigate an inevitable phenomenon of population ageing, which has impact on nation’s development as well as on quality of life of population, health seeking behaviour and health service utilisation need to be increased, especially in rural areas.

Aim: To assess health seeking behaviour, identify hurdles and measure health services utilisation.

Materials and Methods: A community based observational descriptive cross-sectional study was conducted with 210 elderly population (60 years of age and above) to assess health seeking behaviour and to measure health service utilisation for the period from October 2020 to October 2021, in rural area of Tasgaon block of Sangli district of Maharashtra by Department of Community Medicine, Government Medical College, Miraj, Maharashtra, India. A pretested, prevalidated, semi-structured proforma and interview schedule were used to collect information. Descriptive statistics along with Chi-square test and Binary logistic regression were used as inferential statistical analysis. The p-value to be significant at p<0.05.

Results: Out of total 210 participants, 48.09% and 51.91% were males and females respectively with male to female ratio of 0.93:1. Mean ages of males and females were 63.85 and 65.23 years respectively.Out of total 210 participants, 82% of participants had atleast one chronic morbidity at the time of study. Musculoskeletal morbidities were most common (46.67%). Among morbid participants, 56% utilised government health facility. Health service utilisation rate was 75.86%. Lack of enough money was most common reason (76.19%) for non utilisation of health services. Gender, educational level, residential arrangements and socio-economic class showed statistically significant association with appropriate or inappropriate health seeking behaviour. About 61% participants showed appropriate health seeking behaviour. The odds of having inappropriate health seeking behaviour were 7.76 and 10.19 times greater for middle class and lower class as opposed to upper class, respectively. Illiterates had 17.53 times higher odds to seek health inappropriately.

Conclusion: Quality of health seeking behaviour can be improved by narrowing gender gap, increasing literacy rate and giving social assistance to elderly persons. It is an important need of hour to pay more attention to age related issues and promote holistic approach to deal with ageing society.


Geriatric population, Health inequality, Treatment, Unmet needs

A sustained change in the age composition of population is continuously experienced by the whole World including India due to increased life expectancy and reduced levels of fertility. People aged 60 years and above are considered as elderly in India. According to Census 2011, 8.6% population was elderly and mostly residing in rural areas (8.8%) than urban areas (8.1%). Percentage change in decadal growth of general population shows declining trends from 24.8% (period 1961-71) to 8.4% (projected in period 2021-31) while that in case of elderly population shows inclined trend from 25.2% (period 1991-2001) to 40.5% (projected in period 2021-31) (1). This phenomenon is recognised as ‘population ageing’ which has impact on not only a country’s development but also quality of life of population (2).

Health seeking behaviour is an effort taken to maintain, attain or regain good health and prevent illness (3). In India, locomotor disability is the most common disability in elderly followed by hearing and visual impairments (more common in rural area). More than 50% of elderly have taken treatment for disability from doctors (1). Health seeking behaviour is prerequisite for health service utilisation and in elderly both of these are mainly affected by presence of affordable and accessible health infrastructure, financial status, health consciousness, locomotive capacity, literacy level, family support, rural-urban gap and gender (4).

A systematic review of 70 research studies (4), a study based on National Sample Survey (NSS) (75th round) (5) and study conducted in rural areas of Telangana (3) between 2015 to 2020 highlighted the factors like illiteracy, poverty, poor health infrastructure and gender inequalities as the main hurdles in health seeking behaviour. To mitigate this and to prioritise the needs of elderly, understanding of factors affecting health seeking behaviour and non utilisation of health services is necessary. As very few studies were conducted in rural setup of Maharashtra and with COVID-19 background with respect to Coronavirus Disease-2019 (COVID-19) centric health services, increased out of pocket health expenditure and fear of getting COVID-19 while utilisation, this study was planned to assess health seeking behaviour, identify hurdles and measure health services utilisation among elderly rural population.

Material and Methods

This was a community based observational descriptive cross-sectional study, conducted from October 2020 to October 2021, undertaken by Department of Community Medicine, Government Medical College, Miraj, Maharashtra, India, at rural area in Sangli district of Maharashtra. The study area is situated 40 kilometres away from district headquarter with total population of about 40,700 with 7868 households (6). Out of this, the total number of elderly people (>60 years of age) is 3,132 according to data available with rural health centre. Permission of Institutional Ethical Committee (IEC) was taken before data collection (Letter no. GMCM/IEC-C/31).

A written informed consent was taken from each study participant before data collection and examination. Assurance of anonymity and confidentiality in local language as well as information about study procedure was given before taking consent.

Sample size calculation: Sample size was calculated for descriptive study design (proportion) by using OpenEpi software. Proportion of participants with health seeking behaviour was 83.7% in previous study (7). By taking 5% as absolute precision and 5% alpha-error, calculated sample size was 210. Systematic random sampling with PPSS (population proportionate to sample size) sampling technique was used to select 210 samples from a total of 20 wards.

Inclusion criteria: All elderly people of age 60 years and above residing in study area and willing to participate in study were included.

Exclusion criteria: People who were not available at the time of home visit for three successive visits, or those residing in study area for less than six months, those elderlies who were seriously ill and not able to give information were excluded from study.


A pilot study was conducted during month of March 2021 to check out the feasibility and correctness of proforma. Data collected during pilot study phase was not utilised in this study. There are 20 wards/administrative areas in study area. A ward wise data of general and geriatric population was collected from rural health centre. After that samples that to be collected from particular ward was calculated by Probability Proportional to Size (PPS) sampling technique. Samples were selected from line listing by lottery method. After that house visits were given by researcher to collect information.

Questionnaire: After explaining study procedure, a pretested, prevalidated, semi-structured proforma and interview schedule were used to collect information about socio-demographic data, socio-economic condition (modified BG Prasad classification) (8), chronic morbidity status, type of health service utilisation, preferred system of medicine used, quality of healthy seeking behaviour and reasons for non utilisation of services. A detailed history of past and present illness was taken. Thorough local and systemic examination was conducted. Anthropometric measurements were taken. Blood pressure measurement and blood sugar estimation was done using calibrated instruments.Blood pressure was measured thrice in right arm at one minute interval using adult cuff size in sitting position. Finally average of second and third observations was considered and the first measurement was discarded. Fasting blood sugar level was measured. Overnight or 8-12 hours fasting was ensured before blood sugar estimation.

Based on the above assessment, provisional diagnosis of morbidity was made. Elderly with atleast one chronic morbidity were considered for inquiry about health seeking behaviour. Seeking health service from trained doctors (Allopathy or AYUSH) from private or government health facility was considered as ‘appropriate health seeking behaviour’ (7). Standard operational definitions and protocols were established before data collection and followed till end of study to avoid bias(es).

Statistical Analysis

Data was recorded in Microsoft (MS)-Excel 2010 application and analysed by using Epi-Info and Statistical Package for Social Sciences (SPSS) version 16.0 software. Descriptive statistics like frequency and proportion were used for qualitative data. Chi-square test and binary logistic regression were used as inferential statistical analysis. The p-value <0.05 to be considered level of significance.


Total of 210 elderly subjects participated in the study and their socio-demographic details have been depicted (Table/Fig 1). Most of the participants of either gender belonged to age group of 60-64 years (39.05%). Religion wise Hindu participants were predominant (70%). About 82% study participants were literate and 18.10% were illiterate. Percentage of illiterate women (22.94%) was more than that of male (12.87%). Among literates, most were educated up to primary level (32.86%). About 39% were widow(er) and unmarried. Nine percent were staying alone while 25% were staying with spouse only. About 72% were financially dependent on children or another person. Most of the study participants belonged to middle class (39.52%) followed by lower class and upper class (Table/Fig 1).

As shown in (Table/Fig 2), mean number of morbidities among total participants were 1.74. Morbidities related to musculoskeletal system were most common (46.66%) among participants of either gender. Among male participants, hypertension was second most common (35.64%) morbidity while among female participants, anaemia was second most common (33.94%) morbidity. Out of total 210 participants, 36 participants (17.14%) did not have any chronic morbidity at the time of study (Table/Fig 2).

Pattern of health services utilisation of 174 study participants having atleast one chronic morbidity at the time of study has been depicted in (Table/Fig 3). Out of total 174 morbid participants, 75.86% utilised either government or private or other type of health services and 24.14% did not utilised any heath service due to various reasons. Among 132 participants, 80% utilised either government health facility or private facility while 19% participants took over the counter medicines. Almost half of the participants preferred allopathy. Interestingly, 5.3% participants were preferred faith healers over established systems of medicine (Table/Fig 3).

(Table/Fig 4) highlighted various reasons of non utilisation of health services. Lack of enough money was most common reason (76.19%) for non utilisation of health services followed by waiting for recovery (54.76%). Fear of getting COVID-19 was third common cause for non utilisation. Ignorance, unaware of own morbidity and unable to reach to health facility were other common reasons (Table/Fig 4).

(Table/Fig 5) shows factors affecting appropriate and inappropriate health seeking behaviours. One study participant having a diabetes was on metformin prescribed by an allopathic practitioner along with one ayurvedic medicine suggested by friend, so, at the time of analysis, it was considered under OTC section (19). But as above participant was taking diabetic allopathic medicine as per prescription, he was considered under appropriate category (Table/Fig 5). Appropriate health seeking behaviour found more in males (72.09%) than females (51.14%). Inappropriate health seeking behaviour was most common among illiterate participants (61.29%) and participants belonging to lower socio-economic class (67.24%). Participants who were financially independent (75%) and staying with family (69.29%) had appropriate health seeking behaviour. Gender, educational level, residential arrangements and socio-economic class showed statistically significant association with type and behaviours of healthcare sought. (Table/Fig 5) also highlights effect of multiple independent factors on health seeking behaviour by binary logistic regression technique. The odds of having inappropriate health seeking behaviour are 7.76 and 10.19 times greater for middle class and lower class as opposed to upper class, respectively. Illiterates have 17.53 times higher odds to seek health inappropriately (Table/Fig 6).


Greater number of elderly population is residing in rural part of India and almost 80% of them had unmet need for healthcare along with poor health seeking behaviour due to multidimensional reasons (5). Present study was conducted at town located near inter-state border (Maharashtra and Karnataka) in Maharashtra to measure health services utilisation and to assess health seeking behaviour among old age population with respect to their chronic morbidities. This study was conducted among 210 elderly participants. Only one-fourth participants were financially independent, rest were dependant on children. Dependency was more in female participants as compared to male participants. In 2011, dependency ratio of old age population in India was around 14% (9). Overall illiteracy rate was 18.10% which was higher in females (22.94%) as compared to males (12.87%). According to World Bank statistics, overall illiteracy rate of India was 25.60% while in males and females; it was 17.60% and 34.21%, respectively, which is higher than findings reported in present study (10).

Important current study findings like demographic factors, population background, morbidity pattern and healthcare services utilisation are highlighted and compared with previous studies done in various parts of India (Table/Fig 7). Health service utilisation noted in current study was much better than studies conducted in different parts of India. Use of government health facilities was comparable with many previous studies except two multicentric studies mentioned in table, where it is greater than findings reported in those studies. Studies conducted in Assam (2015-16) and Puducherry (2015) reported 3-4.5% of subjects went to faith healers. Literacy level of study subjects, peer pressure and less faith in system of medicine were the reasons behind that (7),(11),(12),(13),(14),(15),(16).

In present study, females had more morbidities compared to males. This may be due to less attention paid by females to their own health. Musculoskeletal problems were most common morbidity in current study. This was due to age related changes. Allopathy was most preferred system of medicine. Almost 6% participants still preferred faith healers over established system of medicine and illiteracy was one of the common reason behind them. Study done in Shimoga by Nandini C and Saranya R, reported government health facility use in 94.3% participants and quacks were visited by 2.9% participants (17). Concurrent findings were reported by Gnanasabai G et al., and Teyib A et al., in their studies. Over the counter drug utilisation was seen in significant number of elderly participants (18),(19).

In present study, 42 participants had suffered from morbidity but did not utilise healthcare facility outside home. Lack of enough money (76.19%) was commonest reason followed by waiting for recovery, fear of getting COVID-19 and unaware about own morbidity were common reasons. Study conducted at Bhopal city in 2016 reported considering age related morbidity (36%) and lack of money were commonest reasons in their study (20).Study done in 2019 in Jaipur reported unawareness, absence of transport facility and cost as common reasons for not utilising healthcare services (21).Concurrent findings were reported by studies done by, Barua K et al., Kumar D et al., and Nandini C and Saranya R (7),(11),(17).

Quality of health seeking behaviour is also an important concept. Depending upon availing evidence based established health services, it was classified into two categories viz., appropriate and inappropriate (7). Appropriate health seeking behaviour was observed more in males as compared to females. Multicentric study done in six states of India in 2019 by Patel R and Chauhan S, reported similar gender difference in their study (16). An inferential statistical analysis highlighted significant statistical association between quality of health seeking behaviour (appropriate and inappropriate) and gender, educational level, residential arrangements and socio-economic class. Age of participants, marital status and financial dependency did not show statistical association. Logistic regression analysis showed elderly study participants with male gender, literates and upper socio-economic class have greater odds of having appropriate health seeking behaviour. In study done by Barua K et al., in Assam, only residential arrangement was significant factor (7). Study done by Baral R and Sapkota P in Nepal, reported ethnicity, religion and type of health problem were significant factors (22). Study based on data of national sample survey done Ranjan A and Muraleedharan VR and pan India study done by Srivastava S and by Gill A reported similar study findings (15),(23).


In current study, out of pocket expenditure of past illness and availability of social assistance measures for health in nearby government health facility were not studied. A multicentric comparative study with different geographical (urban, rural and tribal) and demographic background along with more independent attributes will be more useful.


This study not only highlighted the chronic morbidity pattern among geriatric population due to senile physical, mental, physiological and biochemical changes but also assess the impact of social factors like financial dependency, poverty, illiteracy, gender inequalities and loss of caring members of family on quality of health seeking behaviour and health services utilisation. Poverty, ignorance and fear of getting COVID-19 were commonest reasons for non utilisation of health services. Gender, literacy level and economic condition had greater impact on health seeking behaviour. Quality of health seeking behaviour can be improved by narrowing gender gap, increasing literacy rate and giving social assistance to elderly persons. Proactive geriatric services should be provided which can cater free of cost or low-cost promotive, preventive, curative and rehabilitative healthcare through specialised geriatric health clinics, mobile clinics, nutritional support and intense Information, Education and Communication (IEC) activities to create awareness. Proper enforcement of existing laws should be done to control problem of over-the-counter drugs and faith healers.


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DOI and Others

DOI: 10.7860/JCDR/2022/52681.16105

Date of Submission: Oct 01, 2021
Date of Peer Review: Dec 03, 2021
Date of Acceptance: Dec 28, 2021
Date of Publishing: Mar 01, 2022

• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

• Plagiarism X-checker: Oct 05, 2021
• Manual Googling: Dec 24, 2021
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